Tuesday, 6 January 2015

Understanding the A&E Crisis in 2015

I usually find myself feeling sympathy with anyone getting the John Humphrys treatment. This extended to Jeremy Hunt working hard to explain why increasing numbers of hospitals are declaring major incidents, because their A&Es reach the point of not being able to cope with demand.

The ground was well prepared by Clifford Mann the spokesman for the College of Emergency medicine, who raised the crucial matter of funding for A&Es, where the tariff does not cover the costs of treatment. This effectively means that hospitals cannot afford to recruit and retain permanent staff and end up with the pernicious and expensive dependence on agency staff. http://www.bbc.co.uk/programmes/p02gcq7d

A manager from one of the hospitals which had declared a major incident also explained the pressures that he was experiencing.  These included: All the bed spaces full, all the overflow beds full, Discharges to community care beds or home difficult, Surrounding hospitals already on ambulance divert and therefore unable to accept a divert from them, the sheer impossibility of getting more staff, as all available agency staff were already spoken for.

Jeremy Hunt of course talked about the extra nurses that they had been employed, and the extra winter funding he had authorised, and he also talked about the growing demand from aging population. He was also gracious about the heroic effort by staff under difficult circumstances.

Jeremy Hunt did not mention the request to Chief execs of Foundation Trusts to see if they have any clever ideas for fixing the problem, but then the results of that plea are not due back to him until later today.

The problems are of course complex, and involve a whole series of organisations trying to find ways to work together to meet the needs of a rapidly aging population. Anyone honestly trying to get to grips with this should have our sympathy, and our support.

The point in the interview where Jeremy Hunt lost my sympathy was when, feeling the pressure, he used the Mid Staffs card. I do understand that in the face of the persistent and growing problems within the NHS the temptation to say “well at least it is not Mid Staffs” is a strong one. What frustrates me is that if we had learned the real lessons from Mid Staffs we might not now be facing a crisis throughout the NHS with so little apparent preparation.

What I think is still escaping Jeremy Hunt, though I think it is understood by growing numbers of health professionals, is that the parallels between the problems that actually existed at Mid Staffs in 2007, and exist in the NHS as a whole now, are very strong.

Staffordshire is a part of the country where people live to be old, and many young people move away for work, so the population here got old a little before it did in other parts of the country.

The “new” element of patient choice led to competition between hospitals for staff and patients. Smaller hospital surrounded by other larger ones found that they were under increasing pressure. More of the profit making elective care drifted away to the bigger neighbouring hospitals, leaving Mid Staffs and other small hospitals increasingly trapped into loss making emergency care.

The fashionable solution of the time, which seems since to have lost its appeal, was for the hospital with the active encouragement of the Department of Health, to become a foundation trust. This was probably the wrong answer. The process of becoming a foundation trust forced the hospital to attempt to balance its books, which it could only do by cutting beds and cutting staff. The application process would certainly not have encouraged the hospital to appeal for help when it needed it.

An additional factor, which was oddly never mentioned in the Mid Staffs inquiry, is that the local authority, faced with the increasing costs of its aging population, took the questionable decision to close most of its loss making care homes, on the basis that public consultation had shown that the majority of people would wish to remain in their own homes. The level of community care needed to support this aspiration did not and probably still does not exist.

With the aging population, cuts to beds, loss of permanent staff, growing dependency on agency staff, and a rapidly escalating “exit block” problem all of the pieces for an A&E crisis were in place. All it took to tip the balance was winter.

If you want to understand what the pressures were like for the staff and patients read this excellent account of what happened when a a neighbouring centre of excellence tipped into a black alert last week. http://t.co/dCR8g4bCuj

There is one substantial difference between the pressures at Mid Staffs in winter 2007 and the pressures on the NHS now. That is the wider awareness of the scale of the problem. In 2007 the staff at Midstaffs were isolated at the centre of a storm. As the hospital beds and the overflow areas filled up and bed blocking became critical they and their managers should have been in a position to call for help, but if they did then no help came.

In Mid Staffs the Emergency staff, and the managers took the blame, for a situation that was entirely beyond their control. I think what we are seeing now, as hospital after hospital declares a major incident, is a refusal to be the fall guys for a hugely complex major problem that is the responsibility of us all.

Mid Staffs is of course a terrifying symbol, largely because of the persistent mis-use of the excess death figures – which never appeared in any report, and do not reflect the facts. I have no doubt at all that there were days in 2007 when the A&E at Mid Staffs, and the emergency wards attached were unpleasant places to be, both for staff and for patients. In part the problems were exacerbated by the pressure to meet waiting time targets, and the unintended consequences of this pressure. The breaches of A&E waiting times, which today’s figures show us http://www.bbc.co.uk/news/health-30679949?ns_mchannel=social&ns_campaign=bbc_breaking&ns_source=twitter&ns_linkname=news_central are now occurring routinely throughout the NHS are just one indication of the huge pressures that staff are experiencing now, which inevitably has an impact on patient experience.

This winter it is much too late for magical solutions. Getting through the pressures is going to take patience and tolerance from everyone. Some of the national papers are requesting stories from people who have experienced A&E and I am sure that stories will be found. It would be great to see papers also exploring some of the potential solutions.  

What I would really like to see, (I am not holding my breath), is the simple recognition that solving these deep problems is difficult, and that we could do better by ending the blame game, trying to understand the complexity, and work towards potential solutions. Understanding the pressures that caused problems at Mid Staffs just a little better would be an excellent place to start.

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